A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Measure the client's vital signs before the client walks.

Determine if the client needs to have a gait belt applied.

Report the onset of any dizziness or lightheadedness.

Instruct the client about signs of orthostatic hypotension.

Offer to assist the client to void prior to walking in the hall.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

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Correct Answer is ["B","E"]

Explanation

Choice A reason: Tinnitus is not an immediate concern in the context of multiple sclerosis.

Choice B reason: Tachycardia should be reported immediately as it could indicate an underlying cardiovascular issue or autonomic dysfunction.

Choice C reason: Tremors are a common symptom of multiple sclerosis and do not require immediate reporting unless there is a significant change.

Choice D reason: Paresthesia is also a common symptom of multiple sclerosis and does not require immediate reporting unless there is a significant change.

Choice E reason: Fever should be reported immediately as it can indicate an infection, which can exacerbate multiple sclerosis symptoms.

A. Ear pain and fever. B. Elevated WBC and sedimentation rate. C. Positive Epstein-Barr, and malaise. D. Increased BUN and serum creatinine.

Correct Answer is C

Explanation

Choice A reason: Ear pain and fever are not specific symptoms of mononucleosis and may indicate other infections such as otitis media.

Choice B reason: Elevated WBC (white blood cell) count and sedimentation rate can be seen in many infections and inflammatory conditions, but they are not specifically diagnostic of mononucleosis.

Choice C reason: Mononucleosis, often caused by the Epstein-Barr virus (EBV), typically presents with a positive EBV test and malaise (general feeling of discomfort or illness). Other common symptoms include fever, sore throat, swollen lymph nodes, and fatigue.

Choice D reason: Increased BUN (blood urea nitrogen) and serum creatinine levels are indicators of kidney function and are not typically associated with mononucleosis.

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A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Correct Answer is ["B","E"]

Explanation

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Correct Answer is C

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

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The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

A client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

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